Overall rating for this trust Requires improvement. Quality Report. Ratings. Are services at this trust safe? Requires improvement

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1 Lewisham and Greenwich NHS Trust Quality Report University Hospital Lewisham High Street Lewisham London SE13 6LH Tel: Website: Date of inspection visit: 7-10 March 2017 Date of publication: 17/08/2017 This report describes our judgement of the quality of care at this trust. It is based on a combination of what we found when we inspected, information from our Intelligent Monitoring system, and information given to us from patients, the public and other organisations. Ratings Overall rating for this trust Are services at this trust safe? Are services at this trust effective? Are services at this trust caring? Are services at this trust responsive? Are services at this trust well-led? 1 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

2 Letter from the Chief Inspector of Hospitals This is the second comprehensive inspection of Lewisham and Greenwich NHS Trust; our first being carried out in At that inspection, we rated the trust as requires across each of the five key questions; safe, effective, caring, responsive and well-led. Due to CQC receiving increased number of complaints and concerns being reported by patients, relatives and staff, we undertook a further inspection of the emergency department and medical services at the Queen Elizabeth Hospital in June We rated both services as requires. This most recent inspection was carried out to determine whether the hospital had made progress following their 2014 comprehensive inspection and 2016 focused inspection. Following this most recent inspection, we have again rated the trust as requires across the five key questions and requires overall. We rated both of the main locations as requires overall. Community services was rated as outstanding overall; this was attributable to the effective care and leadership of children, young people and family community services provided in the borough of Lewisham. In light of the concerns which existed with regards to the emergency care pathway at Queen Elizabeth Hospital, a system wide risk summit was convened shortly following the announced inspection period. Stakeholders across the health economy committed to work with the trust to address the concerns including patient flow across the emergency pathway. A subsequent visit to the trust on 19 May 2017 by a small team of inspectors and a specialist advisor for emergency medicine confirmed that a number of changes had been made to the emergency pathway. This included increased monitoring of the quality of care provided within the emergency department; improved access to physical beds as compared to trolley's, so as to reduce the risk of patients developing pressure damage; improving ownership and relations of the challenges faced by those working in the emergency department. The trust acknowledged that significant work was still required across the emergency care pathway however representation of key members of the health system were present on 19 May 2017 and all were committed to working together to improve outcomes for patients. Our key findings were as follows: Despite a period of three years since our last comprehensive inspection, there remained areas of unresolved risks and areas for significant. This included the acute emergency pathway at Queen Elizabeth Hospital. In part, a lack of decisive decision making by the trust leadership team contributed to a lack of overall progress across the organisation. In some areas, safeguarding training rates and mandatory training rates fell well below the trust s target. There were significant shortages of medical, nursing and allied health professional staff in most departments which were having an impact on delivery of care and patient safety. Although the trust was actively trying to recruit into vacant posts there was limited evidence of success. In some areas, principally surgery, medicines management processes were not in line with hospital policy or national guidance. In medical care, infection control processes, including waste management and adherence to the control of substances hazardous to health guidance, was variable. In surgery, we observed numerous breaches of Infection Prevention and Control (IPC) policy, potentially placing patients at significant risk of infection. In maternity and gynaecology we found the cleanliness of the environment and some equipment to be of a poor standard, even where green I am clean stickers had been used to show that surface areas and equipment had been cleaned that day. In outpatients the environment in general diagnostic imaging was not fit for purpose. Whilst care was in line with relevant National Institute for Health and Care Excellence (NICE) and other national and best practice guidelines, there was a risk 2 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

3 to clinical outcomes and patient safety due to maternity guidelines not being merged across the Lewisham and Greenwich sites and some guidelines also being out of date. The hospital was not providing responsive care in all areas. The provision of end of life care across the organisation was inadequate. There was variation in the level of understanding of services provided to patients. Some progress had been made in meeting the needs of patients living with dementia including increased activities, s to the environment and the introduction of a team volunteers who were being trained in working with people with dementia, which included providing enhanced care. Staff had a good understanding of consent process and recognised when the best interests of the patients had to be considered. Staff obtained consent from children and young people and parents involving both the child and the person with parental responsibility in obtaining consent where appropriate. Services had risk registers, but not all of the risks identified during the inspection were recorded on the registers and some risks, critical care and services for children and young people, had been on the register for up to three years without any action being taken. We also found a lack of ownership of the registers in some services with no evidence that risks were regularly reviewed. We saw several areas of outstanding practice including: The speech and language therapy manager had implemented a risk feeding protocol following a successful research pilot project. This resulted in demonstrable outcomes for patients, including a 10% reduction in the admission of patients with dysphagia through more effective feeding regimes. As part of the project new guidance was issued for patients and staff and a risk feeding register was implemented to help the multidisciplinary team track patients cared for under the new protocol. Staff in the Trafalgar Clinic provided care and treatment for patients in a nearby prison. Each patient s records were maintained on the service s electronic patient record system. This meant when a patient left the prison service, there was no disruption in care or treatment because clinical staff always had access to this. In addition, if the patient moved out of the area, the electronic records could easily be shared with pharmacists and health workers in the offender resettlement programme. This meant patients received continual care and were at reduced risk of developing health problems associated with an interruption to antiretroviral therapy. In the two years prior to our inspection, sexual health and HIV services recruited up to 50% of the participants for the trust s whole clinical trial and research portfolio. This resulted from a policy of proactive and early-adoption participation that was part of a two-year strategy to improve participation in research in other hospital departments and services. In critical care there was a dynamic programme of research and development enabled by the full time appointment of a research nurse working with doctors including consultants. Examples of research studies completed in the past year included a study exploring the relationship between family satisfaction and patient length of stay, and a pilot study looking at the improved physiotherapy outcome measure by the use of cycle ergometry in critical care patients. The trust recognised only a small sample size was used for each study. However, there were also areas of poor practice where the trust needs to make s. Importantly, the trust must: Review and improve the systems for monitoring and improving the quality and safety of care including attendance at key meetings in ED, surgery, critical care, services for children and young people and end of life care. It must ensure all risks are included on risk registers and are regularly reviewed and updated and carry out audits to monitor the effectiveness of treatment and care. The trust must introduce mechanisms designed to assure the board that any mitigations instigated are implemented and reviewed regularly. Ensure all relevant risk assessments are carried out on patients. Ensure medical and nursing staffing levels are in line with national standards and service specifications. 3 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

4 Ensure that patients are cared for in areas that are appropriate to their needs and have sufficient space to accommodate all equipment and does not compromise their safety and staff have the relevant skills and knowledge to care for them. Ensure patients requiring end of life care receive appropriate and timely care. Improve patient flow across the organisation. In addition the hospital should: Work to share and embed learning from incidents in all services and cross site. Ensure staff comply with infection prevention and control policies and procedures. Ensure staff working on medical wards and in end of life care have the values and attitude necessary to treat patients, their relatives and visitors with dignity and respect. This includes staff treating them in a caring and compassionate way at all times. Ensure medical patients are appropriately reviewed when they are cared for on other wards and that all staff know who is responsible for them and they are contactable. Ensure that patient records are stored and held securely in one document. Ensure all patients have their pain assessed and receive analgesia in a timely manner Improve compliance with mandatory training completion rates for modules that are below the trust target in all staff groups. In critical care consider ways to introduce multidisciplinary meetings and ward rounds to review care and treatment of patients. Ensure there are ongoing arrangements for measuring and reporting patient satisfaction in critical care. Review the arrangements for bereavement services. In critical care, ensure formal arrangements for emotional and psychological support of patients and families including access to clinical psychologists are in place. Review the environment and waiting times for women using the gynaecology service Ensure patients who are at the end of their life, and their relatives, are afforded privacy. Improve cross site working in all services. Work to reduce the number of cancelled operations and improve referral to treatment times and reduce the did not attend (DNA) rate for outpatient appointments. Respond to complaints within agreed timescales. Improve communication and working relationships between different staff groups. Provide sufficient staff to care for patients who need one to one care. Identify ways to empower and support staff to make s and take the lead in decisions and s in their services. Professor Edward Baker Chief Inspector of Hospitals 4 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

5 Background to Lewisham and Greenwich NHS Trust Lewisham and Greenwich NHS Trust was formed in October 2013 by the merger of Lewisham Healthcare Trust and the Queen Elizabeth Hospital Greenwich (following the dissolution of the South London Healthcare Trust by the Trust Special Administrator). The trust has main services on both its Lewisham and Greenwich sites; additionally it has some surgery and some outpatient clinics at Queen Mary Hospital in Sidcup. The Trust is an integrated trust, providing community health services across the borough of Lewisham. Number of beds The trust has a total of 1,083 beds spread across various core services: 600 Medical beds (594 Inpatient, 6 day case) 211 Surgical beds (191 Inpatient, 20 day case) 97 Children s beds (81 Inpatient, 16 day case) 123 Maternity beds (123 Inpatient) 36 Critical Care beds (36 Inpatient) 16 End of Life Care beds (14 Inpatient, 2 day case) Population served The trust primarily serves a population of 500,000 covering (in the main) the boroughs of Lewisham, Bexley and Greenwich. The trust serves an area of high deprivation. Health and deprivation The health of people in Lewisham is varied compared with the England average. Lewisham is one of the 20% most deprived districts/unitary authorities in England and about 26% (16,300) of children live in poverty. Life expectancy for both men and women is lower than the England average. The health of people in Greenwich is varied compared to the England average. Deprivation is higher than average and about 25% (13,600) children live in poverty. Life expectancy for both men and women is lower than the England average. Clinical Commissioning Group The trust's main CCGs are: (Clinical Commissioning Group) is Lewisham CCG, Greenwich CCG and Bexley CCG. Budget and spending For the latest financial year, 2015/16, the trust had an income of 519 million, and costs of 529 million, meaning it had a deficit of 10 million for the year. The trust predicts that it will have a deficit of 23 million in 2016/17. For the period October 2015 to September 2016 the trust had a deficit of 12 million. 5 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

6 Inspection history We previously inspected the trust using our comprehensive inspection methodology in February We chose to inspect the trust in 2014 because both University Hospital Lewisham and Queen Elizabeth Hospital were identified as being high risk services according to our intelligent monitoring model. This model looks at a wide range of data, including patient and staff surveys, hospital performance information and the views of the public and local partner organisations. We did not inspect the community services provided by the trust at the time of the 2014 inspection. As a result of the inspection, we rated the trust as requires overall and across each of the five domains; safe, effective, caring, responsive and well-led. Due to CQC receiving increased number of complaints and concerns being reported by patients, relatives and staff, we undertook a further inspection of the emergency department and medical services at the Queen Elizabeth Hospital in June We rated both services as requires. This most recent inspection was carried out to determine whether the trust had made progress following their 2014 comprehensive inspection. We inspected each of the eight core services across both University Hospital Lewisham and Queen Elizabeth Hospital. We also inspected the community services for children, young people and famillies and community adult services. Our inspection team Our inspection team was led by: Chair: Dr. Timothy Ho (Medical Director, Frimley Health NHS Foundation Trust Head of Hospital Inspections: Nick Mulholland, Care Quality Commission The team included CQC inspectors, inspection managers, assistant inspectors, pharmacist inspectors, inspection planners and a variety of specialists. The team of specialists comprised of a consultant in emergency medicine, consultant rheumatologist, general and vascular surgeon, consultant in neuroanaesthesia and critical care, consultant obstetrician, consultant neonatologist, consultant paediatrician, consultant clinical oncologist and a consultant in palliative care medicine. We were also supported by: senior sister for emergency care; general emergency nurse; infection prevention and control lead nurse; assistant chief nurse; major trauma and orthopaedic nurse specialist; theatre manager; intensive care nurse; head of midwifery; paediatric modern matron; paediatric staff nurse; district nurse; health visitor; occupational therapist; physiotherapist and a senior quality and risk manager. How we carried out this inspection To get to the heart of patients experiences of care, we always ask the following five questions of every service and provider: Is the service safe? Is the service effective? Is the service caring? Is the service responsive to people s needs? Is the service well-led? The inspection team inspected the following core services: Accident and emergency Medicine Surgery Critical care Maternity & gynaecology Children and young people End of life care Outpatients and diagnostic imaging Community children, young people and famillies Community adult health services We also reviewed sexual health services as part of this inspection due to the overall activity of the service. Leadership and governance arrangements for this 6 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

7 service fall within the scope of the Women's and sexual health division of the trust and so we have reported our findings within the maternity and gynaecology reports. Before visiting, we reviewed a range of information we held and asked other organisations to share what they knew about Lewisham and Greenwich NHS Trust. These included local clinical commissioning groups (CCGs); local quality surveillance groups; the health regulator, NHS Improvement; NHS England; Health Education England (HEE); College of Emergency Medicine; General Medical Council; Health & Safety Executive; Health and Care Professions Council; Nursing and Midwifery Council; Parliamentary and Health Service Ombudsman; Public Health England and local Healthwatch groups. We carried out an annnounced inspection of the trust between 7 and 10 March We undertook additional unannounced inspections on 11, 12, 21, 22 and 25 March We visited both the Queen Elizabeth Hospital and University Hospital Lewisham, as well as spending time speaking with staff and patients who were accessing community services within the London Borough of Lewisham. Both prior to and during the inspection we undertook a range of focus group meetings with staff from different roles and grades. We also facilitated focus groups with staff from black and ethnic minorities. We spoke with approximately 550 members of staff from across a range of specialities and grades of seniority. We interviewed members of the executive and non-executive board including the chief executive and the chair. We spoke with approximately 300 patients and relatives and reviewed a wide range of documentation submitted before, during and following the inspection. What people who use the trust s services say Friends and family test The trust s Friends and Family Test performance (% recommended) was generally about the same as the England Average between December 2015 and November In latest period, November 2016 trust performance was 95 % compared to the England average of 95 %. Cancer patient experience survey For Lewisham and Greenwich Trust in 2015, there are 50 scored questions. Lewisham and Greenwich Trust did not score any questions above the expected range; it was below the expected range in 9 and within the expected range on the other 41. Those question in which the trust was below the expected range include: Hospital staff gave information about support groups Hospital staff gave information about impact cancer could have on day-to-day activities Groups of doctors or nurses did not talk in front of patient as if they were not there Patient had confidence and trust in all doctors treating them Hospital staff definitely did everything to help control pain Given clear written information about what should / should not do post discharge Staff told patient who to contact if worried post discharge Patient definitely given enough support from health or social services during treatment Hospital and community staff always worked well together Patient Led Assessments of the Care Environment The trust performed about the same as the England average in the Patient-Led Assessments of the Care Environment (PLACE) 2016 for assessments in relation to Food, Privacy/dignity/wellbeing and Facilities. Trust scores were in line with the England average in relation to food; 85.52% compared to 85% nationally. CQC Inpatient Survey 2015 In the CQC Inpatient Survey 2015, the trust performed better than other trusts in none of the 12 questions examined by the CQC, about the same as other trusts for ten questions and worse than other trusts in two questions. The trust performed worse than other trusts for the following questions: 7 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

8 Were hand-wash gels available for patients and visitors to use? When you had important questions to ask a nurse, did you get answers that you could understand? Facts and data about this trust Activity and patient throughput From August 2015 to July 2016 the trust had: 213,271 A&E attendances. Queen Elizabeth hospital 92,771 University Hospital Lewisham 120, ,155 Inpatient admissions. From July 2015 to June ,852 Outpatient appointments. Queen Elizabeth Hospital 338,572 University Hospital Lewisham 288,280 From April 2014 to March ,151 Births. Queen Elizabeth Hospital 4,200 University Hospital Lewisham 3,951 1,903 Referrals to the specialist palliative care team. Queen Elizabeth Hospital 1,092 University Hospital Lewisham 555 Community services ,361 Surgical spells. Queen Elizabeth Hospital 9,501 University Hospital Lewisham 11,005 Queen Marys Hospital 1,855 Safe: Between January 2016 and December 2016, the trust reported three incidents which were classified as Never Events. In accordance with the Serious Incident Framework 2015, the trust reported 48 serious incidents (SIs) which met the reporting criteria set by NHS England between January 2016 and December 2016 Of these, the most common type of incident reported was Sub-optimal care of the deteriorating patient meeting SI criteria, 15% (7) of all incidents reported. The second highest categories reported were Diagnostic incident including delay meeting SI criteria (including failure to act on test results), 10% (5) of all incidents and Maternity/Obstetric incident meeting SI criteria: mother only, 10% (5) of all incidents reported. There were 11,232 incidents reported to NRLS between January 2016 and December ,410 incidents resulted in no harm/near miss; 2,579 resulted in low harm; 231 resulted in moderate harm; 10 resulted in severe harm and 2 resulted in death. There were two cases of Meticillin resistant Staphyloccous aureus (MRSA) reported between August 2015 and July Trusts have a target of preventing all MRSA infections, so the trust failed to meet this target within this period. Additionally, the trust reported 16 Meticillin sensitive Staphylococcus aureus infections and 23 Clostridium difficile (C.DIff) infections during the same period. Responsive The main reasons for delayed transfer of care at the trust were Waiting Further NHS Non-Acute Care (33.3 %), followed by Awaiting Nursing Home Placement or Availability (26.3%). This was recorded between December 2015 and November From Q1 2015/16 to Q1 2016/17 bed occupancy rates at the trust were higher than the England average with the exception of Q4 2015/16 when occupancy rates were equal to the England average. In Q2 2016/17 occupancy rates were lower than the England average. The overall trend shows slight variations from Q1 2015/16 to Q1 2016/ 17 though occupancy rates have declined to below the England average in Q2 2016/17. Between December 2015 and November 2016 there were 872 complaints about the trust. The trust took an average of 56 calendar days to investigate and close complaints, this is not in line with their complaints policy, which states complaints should be responded to within 25 days. Well-led The trust s sickness levels between September 2015 and July 2016 were lower than the England average. Rates for the trust were below the England average from September 2015 to April 2016 with a noticeable decline in 8 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

9 January Rates were slightly higher and marginally worse than the England average in May 2016 and July The overall trend for the period remained mostly stable with only slight variations month on month In the 2016 NHS staff survey, the trust staff engagement score was 3.79; this was similar to the trust's engagement score for 2015 (3.78). The response rate for the 2016 staff survey result whilst marginally higher when compared to the 2015 response rate (29.5% vs 27.2%), the trust response rate was significantly worse than the national average of 44%. In the NHS Staff Survey 2016, the trust performed better than other benchmarked trusts in two questions, about the same as other trusts in 14 questions and worse than other trusts in 16 questions. The top 5 key findings for the 2016 staff survey results were: Key finding 6 - Percentage of staff reporting good communication between senior management and staff Key finding 7 - Percentage of staff able to contribute towards s at work Key finding 12 - Quality of appraisals Key finding 13 - Quality of non-mandatory training, learning or development Key finding 32 - Effective use of patient/service user feedback. The bottom 5 key findings for the 2016 staff survey results were: Key finding 11 - Percentage of staff appraised in the last 12 months Key finding 16 - Percentage of staff working extra hours Key finding 17 - Percentage of staff feeling unwell due to work related stress in the last 12 months Key finding 27 - Percentage of staff/colleagues reporting most recent experience of harassment, bullying or abuse Key finding 28 - Percentage of staff witnessing potentially harmful errors, near misses or incidents in the last month 9 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

10 Our judgements about each of our five key questions Rating Are services at this trust safe? We rated safe as requires because: Vacancy rates, turnover and sickness absence were all above the trust's planned levels. Bank and agency staff covering shifts received varying levels of support to enable them to be effective. Medicines were not always managed and maintained in a safe and effective way. Learning from incidents was varied across the organisation. There was limited assurance about the safety of patients in particular in relation to the monitored bays on the Medical Admissions Unit (MAU) and the Coronary Care Unit (CCU). Patients in these areas had clear level two needs but the hospital did not recognise these areas as level two areas. This meant patients did not receive the standard of care they would normally receive under the Faculty of Intensive Care Medical (FICM) guidance. Mandatory training completion rates mostly fell below the hospital s target of 85% for both medical and nursing staff. The standard of infection control processes, including waste management and adherence to the control of substances hazardous to health guidance, were variable. Hazardous waste was not always managed in line with national and international best practice safety guidance, including in storage and access control. Duty of Candour The duty of candour is a regulatory duty that relates to openness and transparency and requires providers of health and social care services to notify patients (or other relevant persons) of certain notifiable safety incidents and provide reasonable support to that person. The trust was aware of its role in relation to the duty of candour regulation which is regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations It sets out specific requirements providers must follow which includes an apology to patients. 10 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

11 Staff we spoke with had a good knowledge of duty of candour or the concept of the regulation. Senior staff were clear about the requirement of the duty and were able to describe examples where-by they had been required to discharge their responsibilities to apply the regulatory requirements. Safeguarding There existed an established adult and children & young people safeguarding committee which was chaired by a non-executive director. Meeting quarterly, the committee considered all elements of safeguarding both vulnerable children and adults. A review of meeting minutes confirmed appropriate challenge and the holding of account existed from the committee to relevant members of staff. For example, the committee considered the trust's compliance with ensuring that all staff were in possession of a recent disclosure and barring service check. As of September 2016, 97% of bank staff and 98.3% of substantive staff were compliant with the trust policy in terms of having undergone a DBS check within the preceding three years. The Director of Nursing and Quality was the named executive safeguarding lead for the trust. There were named safeguarding nurses, midwives and doctors in post at the time of the inspection. The committee further considered trust compliance with mandatory safeguarding training. The trust set a target of 85% for completion of safeguarding training. The trust have reported 7 different modules for safeguarding for medical & dental staff at QEH. They are: Safeguarding adults non clinical level 1, of which compliance was at 100% for the pathology team. Safeguarding adults clinical level 2, of which there were 6 staff groups within medical and dental at QEH attained a mean compliance rate of 79%. Both reported staff groups for CYP Level 1 were at 100% Mean training compliance rates for level two children and young people training was 68%. Mean training compliance rates within medical and dental services at QEH for CYP L3 core safeguarding was 81%. 11 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

12 Mean training compliance rates within medical and dental services at QEH for CYP level 3 specialist training was 57.5%. However, one staff group (197L3 Children services) were reported within the L4 CYP module attained 100% training compliance. Nursing and midwifery staff at Queen Elizabeth Hospital exceeded the target of 85% for all four modules for which data were provided. At University Hospital Lewisham, compliance with safeguarding within medical and dental services was as follows: 100% compliance with safeguarding adults, level 1 non clinical for the sole staff group required to undertake the training. Safeguarding adults Level 2 (clinical); 7 different staff groups within medical and dental. Overall mean compliance rate of 72% Two staff groups within medical and dental required to undertake safeguarding children and young people level 1. Overall mean compliance rate of 100%. Four staff groups within medical and dental required to undertake safeguarding children and young people level 2. Overall mean compliance rate of 52%. However, it is important to note that corporate services and children services both attained 100% in safeguarding children and young people, level 3 core. 79% mean compliance across the 6 medical and dental staff groups requiring safeguarding children and young people, level 3 core training. 87.5% compliance across the two staff groups required to undertake children and young people L3 specialist training. 100% compliance across the single staff group required to undertake level 4 children and young people training. Nursing and midwifery staff at University Hospital Lewisham had a 100% completion rate for three of the seven modules. Three modules met and exceeded the trust target of 85%. The remaining module, Safeguarding Children & Young People Level 3 Specialist, had a training completion rate of 41% well below the trust target. Incidents The trust had a current incident and serious incident reporting and management policy and procedure in place. This policy had been developed by the heads of governance and patient safety and had been reviewed by a range of professionals including the medical director, patient safety managers head of clinical effectiveness and divisional governance managers. The policy had been approved by the quality and safety committee 12 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

13 on 1 December 2016 and was scheduled for ratification by the Integrated governance committee on 31 January A review of the Integrated Governance committee to the board on 14 February 2017 confirmed that the policy had been duly ratified. The policy clearly defined roles and responsibilities for all staff across the organisation. Staff from across the organisation were aware of their responsibilities in regards to reporting witnessed incidents and were conversant with where to locate the incident reporting policy. However, there was varying performance in regards to how staff learnt from incidents. Whilst we observed some areas of good practice in terms of how learning was shared, some clinical areas were no so good. Some staff reported not receiving feedback from incidents they had reported whilst other staff were able to describe scenarios when they had reported incidents and could describe the learning that had taken place as a result. The board was sighted on deep dive incident reports including an annual report into serious and red incidents and monthly serious incident report updates. Following receipt of the June 2016 serious incident report, the board had requested a comprehensive review of the wider safety and quality issues arising from within the radiology service. A thematic review was therefore carried out by the the clinical director for radiology, two governance managers and the head of governance. Four key themes associated with the quality and safety of radiology services were identified including workforce, infrastructure, communication and information technology. Discussions with members of both the executive and non executive team during the inspection confirmed that the board had been sighted on the findings of the thematic review and were aware of the 5 year imaging strategy including a drive to attain an award of the Imaging services Accreditation scheme. Never Events are serious incidents that are wholly preventable, where guidance or safety recommendations that provide strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers. Between January 2016 and December 2016, the trust reported three incidents which were classified as never events. We reviewed the route cause analysis and investigation details for two of the three never events. One never event occurred within the surgical division and related to an epidural pump which was wrongfully connected to an intravenous cannula. The patient subsequently received one dose of local anaesthetic and opiate via the incorrect route. Lessons learnt included 13 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

14 retraining for staff and a set of protocols shared across both hospital sites to ensure this did not happen again. The trust had applied the duty of candour with the patient and family and they had received a finalised version of the investigatory findings. The resulting action plan was monitored at the surgical clinical governance meeting. In accordance with the Serious Incident Framework 2015, the trust reported 48 serious incidents (SIs) which met the reporting criteria set by NHS England between January 2016 and December Of these, the most common type of incident reported was Sub-optimal care of the deteriorating patient meeting SI criteria, which contributed towards 15% (7) of all serious incidents reported. The second highest categories reported were diagnostic incidents including delay (including failure to act on test results) which accounted for 10% (5) of all serious incidents and Maternity/Obstetric incidents which impacted on the mother only accounting for 10% (5) of all serious incidents reported. Mortality and morbidity meetings were set to take place monthly, in order to review patient deaths in a timely manner. There was variation across the trust in terms of the frequency and quality of these meetings. The Medical Director was striving to ensure that a robust and effective review process existed across the organisation, however acknowledged that some directorates performed better than others and that this variation was being addressed. The board had been sighted on the concerns of the medical director in terms of the quality of reviews of deaths; the medical director provider a report to the trust board on 13 December 2016 which concluded that whilst the trust mortality review committee was reviewing the quality of care and identified themes, some clinical areas were not investigating deaths appropriately. The trust had identified a clinician to lead the agenda and included the introduction of a mortality review tool endorsed by a Royal College. Staffing As of January 2017 Lewisham and Greenwich NHS Trust reported a vacancy rate of 17% which equated to 1,159 vacant posts. Nursing and midwifery reported the highest vacancy rate with 346 vacant posts. As at January 2017, the trust reported a turnover rate of 14% which whilst in-line with the national average of 14.1%, was higher than the trust target of 12%. 14 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

15 Despite the vacancy rate within critical care, the service was able to maintain a nurse to patient ratio in the ITU at 1:1 and in the HDU; the nurse to patient ratio was always 1:2. In addition, whilst the highest number of vacancies existed within nursing and midwifery, as of January 2017, the trust reported average fill rates for registered nurses was 95.9% in the day and 102.1% at night. For care staff, the average fill rate was 94.7% during the day and 109% at night. The trust reported an overall excess of 0.4% against planned hours; this was a marginal against previous performance. The neonatal unit (NNU) did not meet national guidelines for staffing. An additional 12 nurses were required in order to meet the demand on the unit. As of January 2017, the trust sickness rate was 4.8% against a target of 3.5%. WhilsA review of sickness rates over time would suggest a deteriorating picture for the trust, with increasing sickness rates apparent over time for Between April 2016 and November 2016, the trust reported a bank and agency usage rate of 13%; A&E reported the highest agency and bank staff usage of 21%. Outpatients reported the lowest usage rate of 4%. Surgery (15%) and Maternity (14%) both reported usage rates above the trust average of 13%. Queen Elizabeth Hospital reported the highest agency and bank staff use within Critical care (20%), Children s Services (19%) and Surgery (18%). Outpatients reported the lowest usage of 5%. The remaining core services reported usage rates between 12% and 16%. Agency and bank usage reached a highpoint in April 2016 (16%) then a decrease from May to November 2016 to between 11% and 14%. Lewisham and Greenwich NHS Trust reported their medical staffing below establishment as of December During December 2016 the trust employed 155 (17%) fewer medical and dental staff than the level determined by the trust to provide high quality care. As at September 2016, the proportion of consultant staff reported to be working at the trust were lower than the England average. The proportion of junior staff (foundation year 1-2) working at the trust were higher than the England average. Out of hours cover arrangements for consultants providing end of care services were unclear. Ward staff had varying levels of understanding of the end of life care provision overnight and at weekends. Are services at this trust effective? We rated effective as requires : 15 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

16 There was not a comprehensive rolling audit programme for the inpatient medical wards. This meant care and treatment were not benchmarked against national best practice guidance. The hospital performed variably in the 2015 Heart Failure Audit and the National Diabetes Inpatient Audit. This included performance better than national average in discharging patients following cardiac care but worse performance in ensuring patients received a specialist foot review within 24 hours of admission. Staff spoke of poor communication within some areas of the hospital that negatively affected patient outcomes. This included contradictory messages to patients by doctors and allied health professionals and a lack of understanding of the use of the rehabilitation care pathway. Further, significant was required for ensuring that cross site working occurred across all specialities and at all professional grades. Not all staff were qualified or had skills they needed to carry out their roles effectively and in line with best practice, including in the medical admissions unit (MAU) and coronary care unit (CCU). In addition, the learning needs of staff were not always identified and training put in place to meet those learning needs. Evidence based care and treatment Care was delivered in line with National Institute of Health and Care Excellence (NICE) guidance in relation to their specific service, including in care of the elderly. However as there was no substantive audit programme, there was not a system in place to monitor compliance with this. Patients in the Trafalgar Clinic received HIV testing and care in line with national guidance from the British Association for Sexual Health and HIV and NICE guidance 60. Local audits in the Trafalgar Clinic included participation in a national British HIV Association syphilis audit, checking cardiovascular disease competencies for HIV positive patients and a qualitative audit of patient attitudes to their medicine plan in preparation for a presentation at a national conference. There was a lack of structured audit activity on inpatient medical wards, which meant senior staff could not be assured care and treatment was benchmarked against local standards. Patient outcomes 16 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

17 Between March 2015 and February 2016, patients had a lower than expected risk of readmission for the top two specialties for elective admissions; medical oncology and clinical haematology. For elective gastroenterology and all non-elective admissions, the risk of readmission was higher than expected. The hospital performed variably in the 2015 Heart Failure Audit. This included better than national average in one of the four standards and worse than national average in two of the four standards relating to in-hospital care. In the seven standards relating to discharge, the hospital performed better than the national average in four standards and worse than the national average in two standards. The hospital performed variably in the 2015 National Diabetes Inpatient Audit. For example, performance was better than the national average in eight metrics and worse than the national average in nine metrics. The largest variation was in the guidance that patients be seen by the multidisciplinary diabetic foot team within 24 hours of admission. In this metric the hospital performed at 42%, compared to the national average of 69%. The trust participated in the 2015 lung cancer audit and the proportion of patients seen by a cancer nurse specialist was 56%, which was worse than the audit minimum standard of 90%. Between June 2016 and November 2016, 71 patients experienced a transfer between the hours of 10pm and 7am. National guidance suggests overnight transfers are related to poor patient outcomes and should be avoided wherever possible. Although the hospital s overall performance in the national Sentinel Stroke National Programme (SSNAP) audit had been downgraded from A to B in the most recent results (March 2017), a grading of B was still above the national average. Queen Elizabeth hospital was level three UNICEF Baby Friendly accredited. The Baby Friendly initiative is based on a global accreditation programme of UNICEF and the World Health Organization. A review had been undertaken in June 2016 that was based on the recommendations of the National Paediatric Diabetes Audit of 2014/15. It found that the hospital had met all of the recommendations except for one which was partially met. The Mothers and babies: reducing risk through audit and confidential enquiries (MBRACE) showed the trust was up to 10% lower than average for neonatal mortality in the country. 17 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

18 The number of under one year olds readmitted following an elective admission of children between September 2015 and August 2016 was too low to be compared to the England average. Readmissions following an elective admission, for children aged one to 17, for the same period was similar to the England average. For readmissions following an elective admission of children aged one and under, between September 2015 and August 2016 no one treatment speciality reported six or more readmissions. Audit programmes for end of life care services fell significantly short for services provided at the Queen Elizabeth hospital. Multidisciplinary working HIV consultants in the Trafalgar Clinic worked with colleagues across the hospital to provide coordinated care for HIV positive patients who may be admitted to or seen in other medical or surgical services. This included well-established links with consultant intensivists in critical care and respiratory consultants. This ensured HIV positive patients with complex conditions, such as co-morbid tuberculosis, to be treated by a multidisciplinary team of specialists. This team also demonstrated significant scope for working with teams outside of the hospital. For example, an advanced nurse practitioner led a prisoner treatment and care programme that provided coordinated care for HIV positive or at-risk prisoners. This service was provided with specialists in drug addiction, social needs and homelessness to ensure patients in prison received targeted care. Clinical nurse specialists provided a sexual health screening service in a community clinic in Greenwich on a weekly basis. The Trafalgar Clinic s clinical director maintained oversight of this and nurses provided a seamless pathway from the community clinic to the hospital service if patients presented with an HIV risk. Sexual health, HIV and contraception staff held a monthly MDT meeting that included all sites in the trust. Where a patient was admitted as a medical inpatient and HIV was the primary cause, they could be cared for in this hospital through multidisciplinary relationships between consultants. This team also maintained close relationships with colleagues at another NHS trust, which would accept patients transfers if more specialist HIV inpatient care was needed. Child and adolescent mental health service (CAMHS) support was provided by two local teams dependent on which borough 18 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

19 the patient was from. We were told by staff that this support was good during the day Monday to Friday but there were challenges for assistance out of hours and at weekends. Out of hours provision was through the adult psychiatry team, with CAMHS advice provided by an adult psychiatry consultant who would contact the CAMHS consultant if required. No CAMHS doctor attended after-hours or at weekends. Peer review of the critical care service identified that multidisciplinary meetings were not taking place for long-term patients. This continued to be the case during the inspection however the trust subsequently reported that MDT working was starting to take place in order to assess and plan care for long term patients. Consent, Mental Capacity Act & Deprivation of Liberty safeguards Staff used the abbreviated mental test (AMT) on admission for each patient and used the score to refer to specialised dementia services if needed. We saw the AMT in use in all of the inpatient records we looked at. The dementia lead monitored Deprivation of Liberty Safeguards (DoLS) applications on a weekly basis at each hospital and circulated a list to the senior medical team each Friday. This meant there was always a record of inpatients with an active DoLS and staff working on a weekend had ready access to this information. The dementia and safeguarding lead had recently completed work with staff at the Queen Elizabeth Hospital to improve their reporting of DoLS applications to the trust s safeguarding team following an audit in July 2016 that indicated DoLS were inconsistently reported. Are services at this trust caring? We rated caring as requires Compassionate care The trust s Friends and Family Test performance (% recommended) was generally about the same as the England Average between December 2015 and November In latest period, November 2016 trust performance was 95 % compared to the England average of 95 %. We observed examples of staff interacting with patients and those close to them with kindness and dignity. Staff told us they remembered that they were also supporting the families of the dying. However, there were also examples where the level of care in terms of ensuring patients were treated with compassion and dignity fell far below the expected standard. 19 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017

20 Cancer patient experience survey For Lewisham and Greenwich Trust in 2015, there are 50 scored questions. Lewisham and Greenwich Trust did not score any questions above the expected range; it was below the expected range in 9 and within the expected range on the other 41. Those question in which the trust was below the expected range include: Hospital staff gave information about support groups Hospital staff gave information about impact cancer could have on day-to-day activities Groups of doctors or nurses did not talk in front of patient as if they were not there Patient had confidence and trust in all doctors treating them Hospital staff definitely did everything to help control pain Given clear written information about what should / should not do post discharge Staff told patient who to contact if worried post discharge Patient definitely given enough support from health or social services during treatment Hospital and community staff always worked well together Patient Led Assessments of the Care Environment The trust performed about the same as the England average in the Patient-Led Assessments of the Care Environment (PLACE) 2016 for assessments in relation to Food, Privacy/dignity/well being and Facilities. Trust scores were in line with the England average in relation to Food; 85.2% compared to 78%. CQC Inpatient Survey 2015 In the CQC Inpatient Survey 2015, the trust performed better than other trusts in none of the 12 questions examined by the CQC, about the same as other trusts for ten questions and worse than other trusts in two questions. The trust performed worse than other trusts for the following questions: Were hand-wash gels available for patients and visitors to use? When you had important questions to ask a nurse, did you get answers that you could understand? Are services at this trust responsive? We rated responsive as requires Service planning and delivery to meet the needs of local people 20 Lewisham and Greenwich NHS Trust Quality Report 17/08/2017